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"Work environments that are high demand and low control are most likely to lead to burnout. ER docs work for somebody else… They are pretty much at somebody else's mercy," says a recently retired emergency department physician. From MedPage Today.

Rates of burnout vary markedly by specialty, but generally the highest rates are found among front-line physicians: family medicine, general internal medicine, neurology, and emergency medicine, and the lowest rates were found among pathology, dermatology, general pediatrics, and preventive medicine, according to a survey of burnoutamong U.S. physicians.

The mean average of those reporting burnout was 45.8%, but the emergency physicians had the dubious distinction of being the specialty with the highest burnout rate: more than 60%.

"Emergency physicians are a little more aware of burnout because of the intensity of their work," said Shay Bintliff, MD, 80, who recently stopped working after 30 years as an ER doctor. "Work environments that are high demand and low control are most likely to lead to burnout. ER docs work for somebody else. They work for a group, a hospital, or a corporation. They don't have a single individual practice where they call the shots. They are pretty much at somebody else's mercy."

An emergency-room doctor in Phoenix said he chose emergency medicine "because you can make a big difference right away. It's a fun job."

"But the problem is, you don't really do that any more. It's less about patient care and more about fluffing patient satisfaction surveys -- all the myriad things that have to be charted for the government to pay you for the work you did, rather than making an immediate difference."

The doctor asked not to be identified by name for fear of endangering his group's contract with the hospital where he works. "If I could find another job where I could find the income I make now, I'd leave in a heartbeat," he said.

But if "front-line" is defined to mean doctors who deal with patients in the most exigent and unpredictable situations, then the work lives of emergency physicians and hospitalist physicians should be examined also.

"Hospitalists are more susceptible to burnout because the work of hospital medicine is really intense," said Vineet Arora, MD, a hospitalist on the faculty of the University of Chicago Pritzker School of Medicine. "You're always on. It's like working ER shifts for 7 days in a row."

The field of emergency medicine is well enough established that certain norms have been developed around flexible shifts and working conditions, she said. In hospital medicine, by contrast, shift work is still new. "The intensity has to be figured out. People are still experimenting with how to get the most bang for the buck. The patients are very sick, and length of stay is short. The hospital is expecting better turnaround. Patients are expecting more, too."

Because of the high patient acuity, sometimes "you can't even get a coffee in your shift, there is so much going on," she added.

Hospitalists were not included as a specialty choice in the burnout study, which was published in Archives of Internal Medicine, but researchers at Johns Hopkins University have been looking at the economic pressures on hospitals and how they affect workload of attending physicians, especially hospitalists.

According to a survey they published inJAMA Internal Medicine, hospitalists frequently reported that excess workload "prevented them from fully discussing treatment options, caused delay in patient admissions and/or discharges, and worsened patient satisfaction. Over 20 percent reported that their average workload likely contributed to patient transfers, morbidity, or even mortality."

Another study, by the Mayo physicians who published the survey of specialties, found that 43.8% of hospitalists were affected by emotional exhaustion and 42.3% suffered from depersonalization. Shockingly, 9.2% of hospitalists reported suicidal ideation in the previous 12 months. About 29% of hospitalists said they were likely to leave their current practice in the next 2 years, and 13 percent said they would definitely leave.

They ranked "loss of autonomy and control over content of clinical work" and "unreasonable quantity of work and pace" as the leading causes of dissatisfaction. "Regulatory and professional liability concerns" came in third.

Henry J. Michtalik, MD, a Hopkins physician, said the problem needs to be understood on three levels: that of the individual, the organization, and the quality of interaction between the organization and individual.

At the individual level are such concepts as coping skills and promoting healthy behaviors. The organization-level concerns would include work process and flow, social work support, and pharmacy support. Individual and organization concerns intersect in such arenas as mentorship, professional development activities, job fit discussions, and responsiveness to concerns.

"The AMA recommended an open discussion," Michtalik told MedPage Today. "But you have to pair the open discussion with action. If it's open discussion without action, that would lead to further depersonalization or cynicism, which would lead to further burnout."

Organizations are taking burnout seriously. They know that to replace a physician costs more than $100,000 in recruitment expenses. But it is only receiving middling attention, Michtalik said. If they want to resolve the issue, hospital and physician group leaders need to make burnout prevention "a priority among priorities," he said.

The Society of Hospital Medicine is operating in the belief that "if we don't address this as a professional society, ultimately a legislator or regulator will address it for us," Michtalik said. "It's better to be part of the solution and a transparent discussion than to have regulations imposed on the work force."

The Phoenix doctor said emergency room physicians have low satisfaction because they are squeezed by things they don't control. For example, Medicare's quality indicators are making doctors accountable for things they have no control over. "Most physicians did not train as hospitality workers, which is what we're more and more asked to be," he said. The latest Press Ganey survey of patient satisfaction "has nothing to do with the actual practice of medicine." The hospital, nevertheless, is investing enormous resources in pushing its patient satisfaction score up beyond 95%.

And as Medicare tries to save money on hospital admissions, ER docs are put in a terrible position, he said. When a patient presents with atrial fibrillation, he or she has to be hospitalized. But Medicare will no longer pay for that admission, saying the patient should be placed in observation status instead. Observation status means the patient is responsible for the hospital bill.

"The worst part is they put you, the doctor, in the position of explaining it," he said. "It's not our choice. We're being blamed for it. It's not a decision in our hands and we can't change it. I've been in situations where people begged me not to make them an observation patient, because they can't afford it." That internal conflict "adds to the amount of stress you're feeling."

But not all emergency physicians are fed up. "I am not burned out -- nowhere close," said Loice Swisher, MD, 51, of suburban Philadelphia. She has felt burned out in the past, especially when her daughter, a special needs child, was younger and required more care.

Today she has reordered her work life to achieve a high level of personal reward. She started working with medical residents and move back toward academic medicine, after many years working in a community hospital setting. The keys, she said, are "CPR: connection, productivity, and rest."

Once she figured out how to achieve that, she hit a new stride in the emergency room.

"Oh, my God, it's the best job in the entire world!" she told MedPage Today. "If I could do this forever, and give the patients the care I want to give, I would love to. Emergency medicine is, I think, the best job in medicine, hands down. I can't imagine anything else I would want to do in medicine."